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Patients name: DOB Date Welcome to the University of Western States clinic. Please fill out both sides of this form. The information you provide will help your physician determine whether Chiropractic

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Anyone who has suffered a work-related injury needs to fill out 'is your injury work' form. This includes employees who have been injured on the job and are seeking compensation or benefits for the injuries sustained. It is important for individuals who have experienced work-related injuries to properly document and report their injuries by filling out this form, as it is often required by employers, insurance companies, or workers' compensation boards for processing claims and providing appropriate assistance.

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